Clone of FY27 Pack N Play Distribution Event Sign Up -Nov 6

Fill out this form to register for the Babies Born Healthy Safe Sleep Education and Pack n Play distribution day on Friday, November 6th! Eligible participants must be in their 34th week as of November 1st, a Medicaid/WIC/SNAP recipient, and enrolled in with a Department of Health Maternal and Child Health Program. If you are unsure - please fill out the form or call us at 410-887-0249.

Today's Date

Date

First Name

Last Name

Date of Birth

Date

Language

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Estimated Date of Delivery

Date

Gestational Age

Insurance Type

MCO if Medicaid is selected

Medicaid Number

Currently Enrolled in WIC

Currently Enrolled in SNAP

Number of babies this pregnancy

Other

Hospital of Delivery

Please select a time that will work for you to meet with us for 30 minutes to review safe sleep and give you the Pack N Play

Upload a photo of your WIC/SNAP/Medicaid card as proof of eligibility here

Babies Born Healthy Safe Sleep Education and Pack N Play Distribution